HCHC Application Form

HODGEMAN COUNTY HEALTH CENTER

An Equal Opportunity Employer Instructions: If there is a question which does
not apply to you, mark. “N/A”. Do not leave any question unanswered. Any false, misleading, or incomplete responses
may result in disqualification for hire or immediate dismissal from employment.

Have you ever been convicted of a felony, or any crime relating to theft or dishonesty, or involving acts of violence? *

YesNo

if Yes

Note A conviction record will not necessarily disqualify an applicant from employment: the circumstances of the conviction will be considered in relation to the nature and duties of the job applied for

Are you a citizen of the United States, or specifically authorized to be employed in the United States? *

YesNo

Note The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if
you are hired. Any offer of employment which you received is contingent upon your providing the documentation and
statement which we will request from you.

PRIOR EMPLOYMENT

Note List your last three jobs, beginning with the most recent (you may omit dates for jobs held more than five years ago).